1. Field of the Invention
This invention relates to surgical instruments and, more particularly, to an instrument that can be used to facilitate suturing and repositioning of a tissue that is accessed through a cavity bounded by the tissue. The invention is also directed to a method of using the instrument, as to assist suturing of vaginal tissue to stable pelvic structure.
2. Background Art
Structural defects of the female pelvis cause a variety of clinical problems including stress urinary incontinence, bladder prolapse or cystocele, rectal prolapse or rectocele, intestinal herniation or enterocele and prolapse of the vaginal vault after hysterectomy. Treatment of these problems has included a myriad of surgical procedures reflecting the inadequacy of any single procedure to effect a highly reliable cure. For instance, there are over 100 different operations for stress incontinence alone.
Vaginal procedures are often unsuccessful. They tend to imbricate attenuated fascia covering the organ but usually do not attach the organ to a stable structure found at a higher level, such as bone or strong fibrous ligament. A transvaginal repair by attaching the vagina to the higher (superior) sacrospinous ligament is effective. However, it is technically difficult and it is prone to serious vascular and nerve injury as it is carried out by feeling rather than visualization.
Abdominal procedures that attach the prolapsed tissue to stable bony or ligamentous areas found at a higher level as the pubic symphysis, Cooper's ligament or the sacrum are more effective. However, they are associated with the morbidity, disability and long hospital stay of a large abdominal incision.
Laparoscopic procedures have been recently described for treating a variety of these conditions. Laparoscopy provides excellent visualization of the target areas through a minimally invasive technique that can be performed on an outpatient basis with short recovery time, small cosmetic scars and potentially low morbidity. However, the development of laparoscopic techniques has been hampered by the lack of specialized instruments for the newly evolving procedures.
Reconstructive suspension procedures require elevation of the vagina to a higher level, closer to or adjacent to a fixed pelvic structure and subsequent attachment of the vagina to the fixed structure either directly with sutures or indirectly through the interposition of a biomembrane mesh. The biologically compatible mesh is attached to the fixed stable structure and to the prolapsed unstable vagina to create a membranous bridge that permits ingrowth of fibrous tissue and the creation of a strong permanent connection between the two sides.
Traditionally, vaginal elevation is accomplished with the human finger. Instruments such as a sponge stick or obturator cannot provide the appropriate position of vaginal elevation because they lack a knuckle or joint to change the direction of the tip from cephalad to anterior, or from cephalad to sideways, which is what is required.
Using the finger of an assistant to provide appropriate vaginal elevation and counter-traction for suturing has several disadvantages:
1. The finger may be punctured inadvertently by the suturing needle. This possibility causes the assistant and surgeon to be apprehensive during the suturing process. The surgeon may take less than optimum full thickness bites into the vaginal wall for fear of puncturing the assistant's finger.
2. The assistant may be fired or distracted and move the position of the finger to an inappropriate location inviting improper placement of sutures and related complications.
3. The assistant's finger may be too short to effect the necessary repositioning of the vagina.